Corporate Travel Insurance Application - PDF

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Corporate Travel Insurance Application - PDF Powered By Docstoc
					                             QBE INSURANCE (AUSTRALIA) LIMITED
                             ABN 78 003 191 035




                                                                                            Corporate Travel Insurance
                                                                                                           Application


 Policy No.                                           Client No.                                          Intermediary No.


 DETAILS OF THE INSURED
     Name of Insured

     Tax Status                   Registered Business Yes            No   ABN                                               Taxable                %

     Address                                                                                                           State          Postcode

     Contact Number               Phone No. (Private)     (   )                            Phone No. (Business)         (    )

                                  Fax No.                 (   )                            E-mail

     Notices to:                  Name

                                  Address                                                                              State          Postcode

     Period of Insurance          From            /           /           to           /            /            at 4 p.m.


 CORPORATE TRAVEL DETAILS
     Please indicate which trips are covered under Authorised Business Travel
       Overseas             Australia Only              Interstate        Local Travel in Excess of 80 KM

     Please nominate insured persons and Time of Operation of Cover required
                                         Category                                  Group 24 Hour          Authorised Business Travel       Other
       CAT 1
       CAT 2
       CAT 3
       CAT 4

     Please indicate benefits required in relation to categories shown above.
                                      Benefit                                      CAT 1                CAT 2               CAT 3          CAT 4
             Death and Capital Benefits                                        $              $                    $                   $
             Weekly Benefits – Injury                                          $              $                    $                   $
             Weekly Benefits – Illness                                         $              $                    $                   $
             Medical and Additional Expenses Overseas                          $              $                    $                   $
             Emergency Travel Assistance                                       $              $                    $                   $
             Baggage and Personal Effects                                      $              $                    $                   $
             Money                                                             $              $                    $                   $
             Personal Liability                                                $              $                    $                   $
             Kidnap and Ransom                                                 $              $                    $                   $
             Loss of Travel Deposits and Additional Expenses                   $              $                    $                   $
             Payment of Excess Following Collision Damage or Theft $                          $                    $                   $
             Other                                                             $              $                    $                   $
             Extra Territorial Cover – Weekly                                  $              $                    $                   $
             Extra Territorial Cover – Any One Event                           $              $                    $                   $
             Political and Other Evacuation                                    $              $                    $                   $



QM227-0105
CORPORATE TRAVEL DETAILS continued
   Please indicate aggregate limit of liability required
    Schedule Flights                      Charter and Small Aircraft         Extra Territorial Workers’ Cover
     $                     Per Event       $                   Per Event      $                     Per any one Period of Insurance


   Have you ever had insurance declined or cancelled, or special terms imposed by an insurer?                           Yes     No
   If "Yes", please give details.




   Have you ever claimed on this Class of Insurance during the last 5 years? If “Yes”, please give details.             Yes     No




   Do you or any subsidiary or associated company own or lease aircraft? If "Yes", please give details.                 Yes     No
   Make of Aircraft                Model              Seating Capacity        No. of Crew      No. of Engines



   Do you have a company ruling limiting the number of employees who may travel together?                               Yes     No
   If "Yes", please give details.




   Please give details of journeys involving air travel likely to be undertaken within the next 12 months.
                                                  Schedule Airline     Chartered Airline      Private Aircraft         Helicopter
                 Number
    Within
    Australia    Average Duration
                 Number
    Overseas     Average Duration
                 Maximum Number of
                 Persons Travelling Together

    Overseas Destinations

   Are there any circumstances with which the company should be made acquainted in order to form a proper
   estimate of the risk? If "Yes", please give details.                                                                 Yes     No




DUTY OF DISCLOSURE
  The law requires you to tell us everything you know (or could reasonably be expected to know in the circumstances) which is relevant
  to our decision to insure you and the terms on which we insure you. This duty applies before you enter into a contract with us, that
  is, before we accept your proposal and also each time before you alter or renew the Policy.
  Each person named as the Insured has the same duty.
  PENALTY FOR NON-DISCLOSURE
  If you do not tell us everything necessary, we may: reduce or refuse to pay a claim; or cancel your Policy. If you act dishonestly, we
  may invalidate the Policy from its beginning and not be bound by it.
  You don’t need to tell us anything which: reduces the risk; is common knowledge; we already know, or ought to know in the
  ordinary course of our business; or we indicate we do not want to know. If you are not sure that something is relevant, it is best to
  disclose it anyway.
PRIVACY

   The QBE Privacy Promise Brochure explains what sort of personal information we collect and hold about you and what we do with
   that information. Please contact your Financial Services Provider to obtain a copy of the QBE Privacy Promise Brochure. A copy of
   the brochure may also be obtained from any QBE Commercial office or from our website at www.qbecommercial.com




DECLARATION AND SIGNATURE

   I/We declare that the particulars are true and correct, that I/We have not withheld information likely to affect the acceptance of this
   application.

   Signature of Insured(s)   X                                                       X
   Position Held

   Date                               /       /                                              /    /



OFFICE USE ONLY
   Premium                                GST                            Government Stamp Duty              TOTAL Amount Payable
   $                              +       $                          +    $                             =    $




          This Policy is underwritten by QBE Insurance (Australia) Limited ABN 78 003 191 035 of 82 Pitt Street, Sydney.

				
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Description: Corporate Travel Insurance Application